What to do for a blood glucose level of hyperglycemia?

Management of Blood Glucose Level of 500 mg/dL

A blood glucose level of 500 mg/dL requires immediate medical attention and treatment with insulin therapy to prevent progression to diabetic ketoacidosis (DKA), which is a life-threatening condition. 1, 2

Initial Assessment

• Evaluate for symptoms of hyperglycemia such as thirst, frequent urination, blurry vision, and assess for more severe symptoms including nausea, vomiting, abdominal pain, and altered mental status 1, 2
• Check for ketones in blood or urine to assess for diabetic ketoacidosis 2, 3
• Assess vital signs, hydration status, and level of consciousness 3
• Evaluate for precipitating factors such as infection, medication non-adherence, or new-onset diabetes 2, 3

Immediate Management

Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr to restore circulatory volume and tissue perfusion 2, 3
• After the first hour, continue fluid replacement based on hemodynamic status, typically at 4-14 mL/kg/hr 2
• Adequate fluid intake is crucial as dehydration increases the risk of complications and hospitalization 2, 4

Insulin Therapy

• For critically ill patients or those with severe hyperglycemia (>500 mg/dL), intravenous insulin infusion is the preferred method 1
• Start continuous intravenous regular insulin at 0.1 units/kg/hr after fluid resuscitation has begun 2, 3
• If glucose does not fall by 50-75 mg/dL in the first hour, double the insulin infusion rate 2, 3
• Once blood glucose reaches 200-250 mg/dL, add dextrose to IV fluids while continuing insulin infusion to prevent hypoglycemia 2, 3

Electrolyte Management

• Monitor serum potassium levels every 2-4 hours as insulin therapy can cause hypokalemia 2, 3
• Begin potassium replacement when serum levels fall below 5.2 mEq/L, provided the patient has adequate urine output 2, 3
• Typical potassium replacement is 20-30 mEq per liter of IV fluid 2, 3

Ongoing Monitoring

• Check blood glucose every 1-2 hours until stable 2, 3
• Monitor electrolytes, blood urea nitrogen, creatinine, and venous pH every 2-4 hours 2, 3
• Assess for signs of cerebral edema, particularly in children and adolescents 2, 3
• Watch for symptoms of hypoglycemia during treatment including sweating, drowsiness, dizziness, anxiety, tremor, and hunger 5

For Non-Critical Hyperglycemia (Outpatient Setting)

If the patient is alert, not in distress, and without signs of DKA:

• Administer subcutaneous rapid-acting insulin at an appropriate dose (typically 0.1-0.2 units/kg) 1
• Ensure adequate hydration with sugar-free fluids 1
• Monitor blood glucose levels every 1-2 hours 1
• Seek medical attention if symptoms worsen or blood glucose remains elevated 1, 5

Prevention of Future Episodes

• Review sick-day management with patients, including when to contact healthcare providers 2, 3
• Advise patients never to discontinue insulin during illness and to seek professional advice early 2, 3
• Educate patients on monitoring blood glucose and urine ketones when blood glucose is >300 mg/dL 2, 3

Complications to Watch For

• Diabetic ketoacidosis: characterized by nausea, vomiting, abdominal pain, and high ketone levels 1, 5
• Hyperosmolar hyperglycemic state: extreme hyperglycemia without significant ketosis, often with altered mental status 4
• Cerebral edema: more common in children, presenting with headache, altered mental status, seizures 2, 3
• Hypokalemia during insulin treatment: can lead to cardiac arrhythmias 5

Pitfalls to Avoid

• Using only sliding scale insulin (SSI) as the sole method of treatment is strongly discouraged as it is reactive rather than preventative 1
• Failing to identify and treat the underlying cause of hyperglycemia 2, 3
• Neglecting to monitor for hypoglycemia when insulin therapy is initiated 5
• Discontinuing insulin therapy too early before the hyperglycemic crisis is fully resolved 2, 3